Provider Demographics
NPI:1295193670
Name:KORY STOTESBERY DO, INC.
Entity Type:Organization
Organization Name:KORY STOTESBERY DO, INC.
Other - Org Name:SF BAY PSYCHIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KORY
Authorized Official - Middle Name:
Authorized Official - Last Name:STOTESBERY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:925-322-0418
Mailing Address - Street 1:1501 N BROADWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-4296
Mailing Address - Country:US
Mailing Address - Phone:925-322-0418
Mailing Address - Fax:
Practice Address - Street 1:1501 N BROADWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-4296
Practice Address - Country:US
Practice Address - Phone:925-322-0418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A12798261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health